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Mayourian J, Sleeper LA, Lee JH, Lu M, Geva A, Mulder B, Babu-Narayan SV, Wald RM, Sompolinsky T, Valente AM, Geva T. Development and Validation of a Mortality Risk Score for Repaired Tetralogy of Fallot. J Am Heart Assoc 2024; 13:e034871. [PMID: 38860401 DOI: 10.1161/jaha.123.034871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/29/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Robust risk assessment is crucial for the growing repaired tetralogy of Fallot population at risk of major adverse clinical outcomes; however, current tools are hindered by lack of validation. This study aims to develop and validate a risk prediction model for death in the repaired tetralogy of Fallot population. METHODS AND RESULTS Patients with repaired tetralogy of Fallot enrolled in the INDICATOR (International Multicenter Tetralogy of Fallot Registry) cohort with clinical, arrhythmia, cardiac magnetic resonance, and outcome data were included. Patients from London, Amsterdam, and Boston sites were placed in the development cohort; patients from the Toronto site were used for external validation. Multivariable Cox regression was used to evaluate factors associated with time from cardiac magnetic resonance until the primary outcome: all-cause death. Of 1552 eligible patients (n=1221 in development, n=331 in validation; median age at cardiac magnetic resonance 23.4 [interquartile range, 15.6-35.6] years; median follow up 9.5 years), 102 (6.6%) experienced the primary outcome. The multivariable Cox model performed similarly during development (concordance index, 0.83 [95% CI, 0.78-0.88]) and external validation (concordance index, 0.80 [95% CI, 0.71-0.90]) and identified older age at cardiac magnetic resonance, obesity, type of tetralogy of Fallot repair, higher right ventricular end-systolic volume index, and lower biventricular global function index as independent predictors of death. A risk-scoring algorithm dividing patients into low-risk (score ≤4) versus high-risk (score >4) groups was validated to effectively discriminate risk of death (15-year survival of 95% versus 74%, respectively; P<0.001). CONCLUSIONS This externally validated mortality risk prediction algorithm can help identify vulnerable patients with repaired tetralogy of Fallot who may benefit from targeted interventions.
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Affiliation(s)
- Joshua Mayourian
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics Harvard Medical School Boston MA USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics Harvard Medical School Boston MA USA
| | - Ji Hae Lee
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics Harvard Medical School Boston MA USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics Harvard Medical School Boston MA USA
| | - Alon Geva
- Department of Anesthesiology, Critical Care, and Pain Medicine, and Computational Health Informatics Program, Boston Children's Hospital and Department of Anaesthesia Harvard Medical School Boston MA USA
| | - Barbara Mulder
- Department of Cardiology Amsterdam University Medical Centre Amsterdam The Netherlands
| | - Sonya V Babu-Narayan
- Royal Brompton and Harefield NHS Foundation Trust National Heart and Lung Institute, Imperial College London United Kingdom
| | - Rachel M Wald
- Division of Cardiology University of Toronto, Peter Munk Cardiac Centre Toronto ON Canada
| | - Tehila Sompolinsky
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics Harvard Medical School Boston MA USA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics Harvard Medical School Boston MA USA
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics Harvard Medical School Boston MA USA
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Leonardi B, Perrone M, Calcaterra G, Sabatino J, Leo I, Aversani M, Bassareo PP, Pozza A, Oreto L, Moscatelli S, Borrelli N, Bianco F, Di Salvo G. Repaired Tetralogy of Fallot: Have We Understood the Right Timing of PVR? J Clin Med 2024; 13:2682. [PMID: 38731211 PMCID: PMC11084704 DOI: 10.3390/jcm13092682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Despite many advances in surgical repair during the past few decades, the majority of tetralogy of Fallot patients continue to experience residual hemodynamic and electrophysiological abnormalities. The actual issue, which has yet to be solved, is understanding how this disease evolves in each individual patient and, as a result, who is truly at risk of sudden death, as well as the proper timing of pulmonary valve replacement (PVR). Our responsibility should be to select the most appropriate time for each patient, going above and beyond imaging criteria used up to now to make such a clinically crucial decision. Despite several studies on timing, indications, procedures, and outcomes of PVR, there is still much uncertainty about whether PVR reduces arrhythmia burden or improves survival in these patients and how to appropriately manage this population. This review summarizes the most recent research on the evolution of repaired tetralogy of Fallot (from adolescence onwards) and risk factor variables that may favor or delay PVR.
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Affiliation(s)
| | - Marco Perrone
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
- Division of Cardiology and CardioLab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | | | - Jolanda Sabatino
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Isabella Leo
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Martina Aversani
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Pier Paolo Bassareo
- School of Medicine, University College of Dublin, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland;
| | - Alice Pozza
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Lilia Oreto
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, 98122 Messina, Italy;
| | - Sara Moscatelli
- Institute of Cardiovascular Sciences University College London, London WC1E 6BT, UK and Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, AO Dei Colli, Monaldi Hospital, 80131 Naples, Italy;
| | - Francesco Bianco
- Cardiovascular Sciences Department, AOU “Ospedali Riuniti”, 60126 Ancona, Italy;
| | - Giovanni Di Salvo
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
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3
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Ishikita A, McIntosh C, Roche SL, Barron DJ, Oechslin E, Benson L, Nair K, Lee MM, Gritti MN, Hanneman K, Karur GR, Wald RM. Incremental value of machine learning for risk prediction in tetralogy of Fallot. Heart 2024; 110:560-568. [PMID: 38040450 DOI: 10.1136/heartjnl-2023-323296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/20/2023] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVE Machine learning (ML) can facilitate prediction of major adverse cardiovascular events (MACEs) in repaired tetralogy of Fallot (rTOF). We sought to determine the incremental value of ML above expert clinical judgement for risk prediction in rTOF. METHODS Adult congenital heart disease (ACHD) clinicians (≥10 years of experience) participated (one cardiac surgeon and four cardiologists (two paediatric and two adult cardiology trained) with expertise in heart failure (HF), electrophysiology, imaging and intervention). Clinicians identified 10 high-yield variables for 5-year MACE prediction (defined as a composite of mortality, resuscitated sudden death, sustained ventricular tachycardia and HF). Risk for MACE (low, moderate or high) was assigned by clinicians blinded to outcome for adults with rTOF identified from an institutional database (n=25 patient reviews conducted by five independent observers). A validated ML model identified 10 variables for risk prediction in the same population. RESULTS Prediction by ML was similar to the aggregate score of all experts (area under the curve (AUC) 0.85 (95% CI 0.58 to 0.96) vs 0.92 (0.72 to 0.98), p=0.315). Experts with ≥20 years of experience had superior discriminative capacity compared with <20 years (AUC 0.98 (95% CI 0.86 to 0.99) vs 0.80 (0.56 to 0.93), p=0.027). In those with <20 years of experience, ML provided incremental value such that the combined (clinical+ML) AUC approached ≥20 years (AUC 0.85 (95% CI 0.61 to 0.95), p=0.055). CONCLUSIONS Robust prediction of 5-year MACE in rTOF was achieved using either ML or a multidisciplinary team of ACHD experts. Risk prediction of some clinicians was enhanced by incorporation of ML suggesting that there may be incremental value for ML in select circumstances.
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Affiliation(s)
- Ayako Ishikita
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Chris McIntosh
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - S Lucy Roche
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Erwin Oechslin
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lee Benson
- Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Krishnakumar Nair
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Myunghyun M Lee
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Michael N Gritti
- Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Kate Hanneman
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Gauri Rani Karur
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Rachel M Wald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Habib E, Srivasthan K, El Masry H. Evaluation and Management of Sudden Death Risk in Repaired Tetralogy of Fallot. J Pers Med 2023; 13:1715. [PMID: 38138942 PMCID: PMC10744881 DOI: 10.3390/jpm13121715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/01/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Although substantial progress has been made to prevent sudden cardiac death in repaired tetralogy of Fallot patients, ventricular arrhythmia and sudden death continue to be major causes of morbidity and mortality in these patients. Greater survival in contemporary cohorts has been attributed to enhanced surgical techniques, more effective management of heart failure, and increased efforts in risk stratification and management of ventricular arrhythmias. More recently, our understanding of predictive risk factors has evolved into personalized risk prediction tools that rely on comprehensive demographic, imaging, functional, and electrophysiological data. However, the universal applicability of these different scoring systems is limited due to differences between study cohorts, types of anatomic repair, imaging modalities, and disease complexity. Noninvasive risk stratification is critical to identify those who may derive benefit from catheter ablation or cardioverter defibrillator implantation for primary prevention. Ultimately, assessment and risk stratification by a multidisciplinary team is crucial to analyze the various complex factors for every individual patient and discuss further options with patients and their families.
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Affiliation(s)
- Eiad Habib
- Division of Internal Medicine, Mayo Clinic, Scottsdale, AZ 85259, USA;
| | | | - Hicham El Masry
- Division of Cardiology, Mayo Clinic, Scottsdale, AZ 85259, USA;
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5
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Kakarla J, Denham NC, Ishikita A, Oechslin E, Alonso-Gonzalez R, Nair K. Risk Stratification for Sudden Cardiac Death in Repaired Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:414-425. [PMID: 38161672 PMCID: PMC10755789 DOI: 10.1016/j.cjcpc.2023.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 01/03/2024]
Abstract
There has been significant progress in the prevention of sudden cardiac death in repaired tetralogy of Fallot. Contemporary cohorts report greater survival attributable to improved surgical techniques, heart failure management, and proactive strategies for risk stratification and management of ventricular arrhythmias including defibrillator implantation and ablation technology. Over the last 25 years, our understanding of predictive risk factors has also improved from invasive and more limited measures to individualized risk prediction scores based on extensive demographic, imaging, electrophysiological, and functional data. Although each of these contemporary scoring systems improves prediction, there are important differences between the study cohorts, included risk factors, and imaging modalities that can significantly affect interpretation and implementation for the individual patient. In addition, accurate phenotyping of disease complexity and anatomic repair substantially modulates this risk and the mechanism of sudden death. Routine implementation of risk stratification within repaired tetralogy of Fallot management is important and directly informs primary prevention defibrillator implantation as well as consideration for proactive invasive strategies including ventricular tachycardia ablation and pulmonary valve replacement. Assessment and risk stratification by a multidisciplinary team of experts in adult congenital heart disease are crucial and critical. Although we have increased understanding, reconciliation of these complex factors for the individual patient remains challenging and often requires careful consideration and discussion with multidisciplinary teams, patients, and their families.
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Affiliation(s)
- Jayant Kakarla
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Nathan C. Denham
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Ayako Ishikita
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Erwin Oechslin
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Krishnakumar Nair
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
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Bitterman Y, Hui W, Fan CPS, Kiss A, Mertens L, Wald RM, Friedberg MK. Electromechanical Dyssynchrony Is Associated With Right Ventricular Remodeling and Dysfunction Independently of Pulmonary Regurgitation Late After Tetralogy of Fallot Repair. J Am Soc Echocardiogr 2023; 36:1315-1323. [PMID: 37356675 DOI: 10.1016/j.echo.2023.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The aim of this study was to investigate the relationship among right ventricular (RV) dilatation, dysfunction, and electromechanical dyssynchrony (EMD) in patients with repaired tetralogy of Fallot (rTOF). METHODS Data from a prospective rTOF registry of subjects with moderate or greater pulmonary regurgitation (PR) and contemporary imaging were analyzed. Electrocardiograms and echocardiograms were analyzed for EMD (prolonged QRS duration [QRSd], echocardiographic septal flash, and mechanical delay) and mechanical dispersion. The relationship among these, RV measurements on cardiac magnetic resonance, exercise capacity, and incident arrhythmia or death was analyzed with adjustment for PR. RESULTS In total, 271 patients with rTOF (42% women; median age, 32 years; interquartile range [IQR], 23-34 years) were included. Patients had moderate to severe PR (median PR fraction, 38%; IQR, 30%-47%), moderate to severe RV enlargement (median RV end-diastolic volume index, 161 mL/m2; IQR, 138-186 mL/m2) and mild RV systolic dysfunction (median RV ejection fraction [RVEF], 44%; IQR, 38%-48%). Eleven patients (4%) experienced ventricular arrhythmia or death. Presence of EMD was associated with larger RV size (RV end-diastolic volume index and RV end-systolic volume index, P = .006 and P < .001, respectively) and lower RVEF (P < .001). A sharp inflection in the relation among QRSd, RV size, and RVEF was observed when QRSd exceeded 150 msec (3.1% decrease in RVEF for every 20-msec increase in QRSd between 160 and 200 msec). Similar inflection points were observed for the mechanical delay between the RV basal-lateral and midseptal segments. The mechanical delay was higher in patients with vs without incident atrial arrhythmia (371 vs 276 msec, P = .014). CONCLUSIONS In adults with rTOF, EMD is independently associated with larger RV size, lower RVEF, and incident atrial arrhythmias.
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Affiliation(s)
- Yuval Bitterman
- Labatt Family Heart Centre, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wei Hui
- Labatt Family Heart Centre, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Ted Rogers Computational Program, Ted Rogers Center for Heart Research, The Hospital for Sick Children, University Health Network, Toronto, Ontario, Canada
| | - Andreea Kiss
- Toronto General Hospital/University Health Network, Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rachel M Wald
- Toronto General Hospital/University Health Network, Toronto, Ontario, Canada
| | - Mark K Friedberg
- Labatt Family Heart Centre, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
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Ghonim S, Babu-Narayan SV. Use of Cardiovascular Magnetic Resonance for Risk Stratification in Repaired Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:393-403. [PMID: 38161667 PMCID: PMC10755838 DOI: 10.1016/j.cjcpc.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/30/2023] [Indexed: 01/03/2024]
Abstract
The risk of premature death in adult patients with repaired tetralogy of Fallot is real and not inconsiderable. From the third decade of life, the incidence of malignant ventricular arrhythmia (VA) is known to exponentially rise. Progressive adverse mechanoelectrical modelling because of years of volume and/or pressure overload from residual pulmonary valve dysfunction and ventricular scar creates the perfect catalyst for VA. Although potentially lifesaving, implantable cardiac defibrillators are associated with substantial psychological and physical morbidity. Better selection of patients most at risk of VA, so that implantable cardiac defibrillators are not inflicted on patients who will never need them, is therefore crucial and has inspired research on this topic for several decades. Cardiovascular magnetic resonance (CMR) enables noninvasive, radiation-free clinical assessment of anatomy and function, making it ideal for the lifelong surveillance of patients with congenital heart disease. Gold standard measurements of ventricular volumes and systolic function can be derived from CMR. Tissue characterization using CMR can identify a VA substrate and provides insight into myocardial disease. We detail risk factors for VA identified using currently available CMR techniques. We also discuss emerging and advanced CMR techniques that have not all yet translated into routine clinical practice. We review how CMR-defined predictors of VA in repaired tetralogy of Fallot can be incorporated into risk scores with other clinical factors to improve the accuracy of risk prediction and to allow for pragmatic clinical application. Finally, we discuss what the future may hold.
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Affiliation(s)
- Sarah Ghonim
- Adult Congenital Disease Unit, Royal Brompton Hospital, London, United Kingdom
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
- National Heart Lung Institute, Imperial College London, London, United Kingdom
| | - Sonya V. Babu-Narayan
- Adult Congenital Disease Unit, Royal Brompton Hospital, London, United Kingdom
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
- National Heart Lung Institute, Imperial College London, London, United Kingdom
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8
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Ishikita A, McIntosh C, Hanneman K, Lee MM, Liang T, Karur GR, Roche SL, Hickey E, Geva T, Barron DJ, Wald RM. Machine Learning for Prediction of Adverse Cardiovascular Events in Adults With Repaired Tetralogy of Fallot Using Clinical and Cardiovascular Magnetic Resonance Imaging Variables. Circ Cardiovasc Imaging 2023; 16:e015205. [PMID: 37339175 DOI: 10.1161/circimaging.122.015205] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 05/12/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Existing models for prediction of major adverse cardiovascular events (MACE) after repair of tetralogy of Fallot have been limited by modest predictive capacity and limited applicability to routine clinical practice. We hypothesized that an artificial intelligence model using an array of parameters would enhance 5-year MACE prediction in adults with repaired tetralogy of Fallot. METHODS A machine learning algorithm was applied to 2 nonoverlapping, institutional databases of adults with repaired tetralogy of Fallot: (1) for model development, a prospectively constructed clinical and cardiovascular magnetic resonance registry; (2) for model validation, a retrospective database comprised of variables extracted from the electronic health record. The MACE composite outcome included mortality, resuscitated sudden death, sustained ventricular tachycardia and heart failure. Analysis was restricted to individuals with MACE or followed ≥5 years. A random forest model was trained using machine learning (n=57 variables). Repeated random sub-sampling validation was sequentially applied to the development dataset followed by application to the validation dataset. RESULTS We identified 804 individuals (n=312 for development and n=492 for validation). Model prediction (area under the curve [95% CI]) for MACE in the validation dataset was strong (0.82 [0.74-0.89]) with superior performance to a conventional Cox multivariable model (0.63 [0.51-0.75]; P=0.003). Model performance did not change significantly with input restricted to the 10 strongest features (decreasing order of strength: right ventricular end-systolic volume indexed, right ventricular ejection fraction, age at cardiovascular magnetic resonance imaging, age at repair, absolute ventilatory anaerobic threshold, right ventricular end-diastolic volume indexed, ventilatory anaerobic threshold % predicted, peak aerobic capacity, left ventricular ejection fraction, and pulmonary regurgitation fraction; 0.81 [0.72-0.89]; P=0.232). Removing exercise parameters resulted in inferior model performance (0.75 [0.65-0.84]; P=0.002). CONCLUSIONS In this single-center study, a machine learning-based prediction model comprised of readily available clinical and cardiovascular magnetic resonance imaging variables performed well in an independent validation cohort. Further study will determine the value of this model for risk stratification in adults with repared tetralogy of Fallot.
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Affiliation(s)
- Ayako Ishikita
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, ON, Canada (A.I., C.M., T.L., S.L.R., R.M.W.)
| | - Chris McIntosh
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, ON, Canada (A.I., C.M., T.L., S.L.R., R.M.W.)
- Department of Medical Biophysics (C.M.), University of Toronto, ON, Canada
- Department of Medical Imaging, University Health Network (C.M., K.H., G.R.K., R.M.W.), University of Toronto, ON, Canada
| | - Kate Hanneman
- Department of Medical Imaging, University Health Network (C.M., K.H., G.R.K., R.M.W.), University of Toronto, ON, Canada
| | - Myunghyun M Lee
- Department of Cardiovascular Surgery, Hospital for Sick Children (M.M.L., D.J.B.), University of Toronto, ON, Canada
| | - Tiffany Liang
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, ON, Canada (A.I., C.M., T.L., S.L.R., R.M.W.)
| | - Gauri R Karur
- Department of Medical Imaging, University Health Network (C.M., K.H., G.R.K., R.M.W.), University of Toronto, ON, Canada
| | - S Lucy Roche
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, ON, Canada (A.I., C.M., T.L., S.L.R., R.M.W.)
| | - Edward Hickey
- Department of Surgery, Division of Congenital Heart Surgery, Texas Children's Hospital, Houston (E.H.)
| | - Tal Geva
- Department of Cardiology, Children's Hospital Boston and Department of Pediatrics, Harvard Medical School, Boston, MA (T.G.)
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children (M.M.L., D.J.B.), University of Toronto, ON, Canada
| | - Rachel M Wald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, ON, Canada (A.I., C.M., T.L., S.L.R., R.M.W.)
- Department of Medical Imaging, University Health Network (C.M., K.H., G.R.K., R.M.W.), University of Toronto, ON, Canada
- The Heart Institute, Hadassah Medical Center, Hebrew University, Jerusalem, Israel (R.M.W.)
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9
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Bokma JP, Geva T, Sleeper LA, Lee JH, Lu M, Sompolinsky T, Babu-Narayan SV, Wald RM, Mulder BJM, Valente AM. Improved Outcomes After Pulmonary Valve Replacement in Repaired Tetralogy of Fallot. J Am Coll Cardiol 2023; 81:2075-2085. [PMID: 37225360 DOI: 10.1016/j.jacc.2023.02.052] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The impact of pulmonary valve replacement (PVR) on major adverse clinical outcomes in patients with repaired tetralogy of Fallot (rTOF) is unknown. OBJECTIVES The purpose of this study was to determine whether PVR is associated with improved survival and freedom from sustained ventricular tachycardia (VT) in rTOF. METHODS A PVR propensity score was created to adjust for baseline differences between PVR and non-PVR patients enrolled in INDICATOR (International Multicenter TOF Registry). The primary outcome was time to the earliest occurrence of death or sustained VT. PVR and non-PVR patients were matched 1:1 on PVR propensity score (matched cohort) and in the full cohort, modeling was performed with propensity score as a covariate adjustment. RESULTS Among 1,143 patients with rTOF (age 27 ± 14 years, 47% PVR, follow-up 8.3 ± 5.2 years), the primary outcome occurred in 82. The adjusted HR for the primary outcome for PVR vs no-PVR (matched cohort n = 524) was 0.41 (95% CI: 0.21-0.81; multivariable model P = 0.010). Full cohort analysis revealed similar results. Subgroup analysis suggested beneficial effects in patients with advanced right ventricular (RV) dilatation (interaction P = 0.046; full cohort). In patients with RV end-systolic volume index >80 mL/m2, PVR was associated with a lower primary outcome risk (HR: 0.32; 95% CI: 0.16-0.62; P < 0.001). There was no association between PVR and the primary outcome in patients with RV end-systolic volume index ≤80 mL/m2 (HR: 0.86; 95% CI: 0.38-1.92; P = 0.70). CONCLUSIONS Compared with rTOF patients who did not receive PVR, propensity score-matched individuals receiving PVR had lower risk of a composite endpoint of death or sustained VT.
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Affiliation(s)
- Jouke P Bokma
- Department of Cardiology, Amsterdam University Medical Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ji Hae Lee
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Tehila Sompolinsky
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Sonya V Babu-Narayan
- Department of Adult Congenital Heart Disease, Royal Brompton Hospital, London, United Kingdom
| | - Rachel M Wald
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam University Medical Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
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10
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Goo HW, Park SH. Identification of rapid progression of right ventricular functional measures using three-dimensional cardiac computed tomography after total surgical correction of tetralogy of Fallot. Eur J Radiol 2023; 164:110856. [PMID: 37150106 DOI: 10.1016/j.ejrad.2023.110856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 04/22/2023] [Accepted: 04/28/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE To identify subsets of patients with tetralogy of Fallot (TOF) after total surgical correction demonstrating the rapid progression of right ventricle (RV) functional measures using cardiac computed tomography (CT) ventricular volumetry. METHODS Rapid or slow progression of RV functional measures was determined in 109 patients with TOF who underwent cardiac CT ventricular volumetry more than twice after total surgical correction. Patient age, body surface area, postoperative days, the time interval between the first and last cardiac CT examinations, and CT-based functional measures were evaluated using binary logistic regression to determine the predictors of the rapid progression. Receiver operating characteristic curve analysis was performed to evaluate diagnostic performance of the potential predictors. RESULTS The rapid progression of indexed RV end-systolic volume (ESV) (≥2.7 mL/m2/year) and indexed RV end-diastolic volume (≥0.9 mL/m2/year) could be predicted by RV ejection fraction (EF) at the last cardiac CT with an odds ratio of 1.340 (95 % confidence interval [CI], 1.122-1.600; p = 0.001) and age at the last cardiac CT with an odds ratio of 8.255 (95 % CI, 1.531-44.513; p = 0.014), respectively. RV EF at the last cardiac CT showed the highest diagnostic performance (area under the curve = 0.799; p < 0.002) for the rapid progression of indexed RV ESV. CONCLUSION Cardiac CT ventricular volumetry can be used to identify patients demonstrating the rapid progression of RV functional measures after total surgical correction of TOF and follow-up imaging protocols can be individually optimized based on initial progression rate.
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Affiliation(s)
- Hyun Woo Goo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
| | - Sang Hyub Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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11
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 713] [Impact Index Per Article: 356.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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12
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Mariucci E, Capicchioni E, Bronzetti G, Careddu L, Gargiulo G, Donti A. Clinical presentation of ventricular arrhythmias in patients with repaired Tetralogy of Fallot. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association. J Cardiovasc Magn Reson 2022; 24:37. [PMID: 35725473 PMCID: PMC9210755 DOI: 10.1186/s12968-022-00843-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA
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14
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association. Circ Cardiovasc Imaging 2022; 15:e014415. [PMID: 35727874 PMCID: PMC9213089 DOI: 10.1161/circimaging.122.014415] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA, (M.A.F.).,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, (M.A.F.)
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA, (S.A.)
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA, (C.B.)
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA, (L.B.)
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA, (T.C.)
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA, (T.J.)
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK, (V.M.)
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA, (M.T.)
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA (C.W.)
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15
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Associations between blood biomarkers, cardiac function and adverse outcome in a young tetralogy of Fallot cohort. Int J Cardiol 2022; 361:31-37. [PMID: 35487320 DOI: 10.1016/j.ijcard.2022.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/30/2022] [Accepted: 04/22/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND To determine the potential prognostic value and clinical correlations of blood biomarkers in a cohort of patients with Tetralogy of Fallot (TOF). METHODS In the setting of multicenter prospective research studies TOF patients underwent blood sampling, cardiopulmonary exercise testing and low-dose dobutamine stress cardiac magnetic resonance (CMR) imaging. In the blood sample NT-proBNP, GDF-15, Galectin-3, ST-2, DLK-1, FABP4, IGFBP-1, IGFBP-7, MMP-2, and vWF were assessed. During subsequent follow-up, patients were evaluated for reaching the study endpoint (cardiac death, arrhythmia-related hospitalization or cardioversion/ablation, VO2 max ≤65% of predicted). Regression analysis was used to explore the correlation between blood biomarkers (corrected for age and gender) and other clinical parameters. The potential predictive value of blood biomarkers and events were assessed with Kaplan-Meier analysis and Cox proportional hazard analysis. RESULTS We included 137 Fallot patients, median age 19.2 (interquartile range: 14.6-25.7) years, median age at TOF-repair 0.9 (0.5-1.9) years. After a median follow-up of 8.7 (6.3-10.7) years, 20 (14.6%) patients reached the composite endpoint. In a multivariable cox-regression analysis corrected for age at study baseline, elevated IGFBP-7 and MMP-2 levels were associated with the composite endpoint. We also noted a correlation between DLK-1 and relative change in right ventricular end systolic volume during dobutamine stress CMR (β = -0.27, p = 0.010), a correlation between FABP4 and Max VO2 (β = -0.41, p ≤0.001 and between MMP-2 and tricuspid valve E/A ratio (β = -0.15, p = 0.037). CONCLUSIONS IGFBP-7, MMP-2 and DLK-1 levels are related to cardiac function and long-term outcome in TOF patients.
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16
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Latus H, Stammermann J, Voges I, Waschulzik B, Gutberlet M, Diller GP, Schranz D, Ewert P, Beerbaum P, Kühne T, Sarikouch S. Impact of Right Ventricular Pressure Load After Repair of Tetralogy of Fallot. J Am Heart Assoc 2022; 11:e022694. [PMID: 35301850 PMCID: PMC9075442 DOI: 10.1161/jaha.121.022694] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Right ventricular outflow tract (RVOT) stenosis after repair of tetralogy of Fallot has been linked with favorable right ventricular remodeling but adverse outcomes. The aim of our study was to assess the hemodynamic impact and prognostic relevance of right ventricular pressure load in this population. Methods and Results A total of 296 patients with repaired tetralogy of Fallot (mean age, 17.8±7.9 years) were included in a prospective cardiovascular magnetic resonance multicenter study. Myocardial strain was quantified by feature tracking technique at study entry. Follow-up, including the need for pulmonary valve replacement, was assessed. The combined end point consisted of ventricular tachycardia and cardiac death. A higher echocardiographic RVOT peak gradient was significantly associated with smaller right ventricular volumes and less pulmonary regurgitation, but lower biventricular longitudinal strain. During a follow-up of 10.1 (0.1-12.9) years, the primary end point was reached in 19 of 296 patients (cardiac death, n=6; sustained ventricular tachycardia, n=2; and nonsustained ventricular tachycardia, n=11). A higher RVOT gradient was associated with the combined outcome (hazard ratio [HR], 1.03; 95% CI, 1.00-1.06; P=0.026), and a cutoff gradient of ≥25 mm Hg was predictive for cardiovascular events (HR, 3.69; 95% CI, 1.47-9.27; P=0.005). In patients with pulmonary regurgitation ≥25%, a mild residual RVOT gradient (15-30 mm Hg) was not associated with a lower risk for pulmonary valve replacement. Conclusions Higher RVOT gradients were associated with less pulmonary regurgitation and smaller right ventricular dimensions but were related to reduced biventricular strain and emerged as univariate predictors of adverse events. Mild residual pressure gradients did not protect from pulmonary valve replacement. These results may have implications for the indication for RVOT reintervention in this population.
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Affiliation(s)
- Heiner Latus
- Clinic for Pediatric Cardiology and Congenital Heart Disease German Heart Centre Munich Munich Germany
| | | | - Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology University Children's Hospital Kiel Kiel Germany
| | - Birgit Waschulzik
- Institute for AI and Informatics in MedicineTechnical University Munich Munich Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology Heart Centre Leipzig-University Leipzig Leipzig Germany
| | - Gerhard-Paul Diller
- Division of Adult Congenital and Valvular Heart Disease Department of Cardiovascular Medicine University Hospital of Muenster Muenster Germany
| | | | - Peter Ewert
- Clinic for Pediatric Cardiology and Congenital Heart Disease German Heart Centre Munich Munich Germany.,DZHK (German Centre for Cardiovascular Research) Partner Site Munich Heart AllianceMunich Germany
| | - Philipp Beerbaum
- Department of Pediatric Cardiology Hannover Medical School Hannover Germany
| | - Titus Kühne
- Clinic for Pediatric Cardiology and Congenital Heart Disease German Heart Centre Berlin Berlin Germany
| | - Samir Sarikouch
- Department of Heart, Thoracic, Transplantation and Vascular Surgery Hannover Medical School Hannover Germany
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17
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Risk Factors of Right Ventricular Dysfunction and Adverse Cardiac Events in Patients with Repaired Tetralogy of Fallot. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910549. [PMID: 34639849 PMCID: PMC8507852 DOI: 10.3390/ijerph181910549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/01/2021] [Accepted: 10/02/2021] [Indexed: 11/17/2022]
Abstract
Aim: This study evaluates the risk factors associated with right ventricular (RV) dilation and dysfunction leading to pulmonary valve replacement (PVR) or adverse cardiac events in repaired Tetralogy of Fallot (rToF) patients. Methods: Data from all rToF patients who underwent magnetic resonance imaging (MRI) evaluation at our hospital between February 2007 and September 2020 were collected. Results: Three hundred and forty-two patients (60% males, 42% older than 18 years), with a median age of 16 years (IQR 13–24) at the time of MRI, were included. All patients underwent complete repair at a median age of 8 months (IQR 5–16), while palliation was performed in 56 patients (16%). One hundred and forty-four patients (42%) subsequently received pulmonary valve replacement (PVR). At the multivariate analysis, male gender was an independent predictor for significant RV dilation, RV and left ventricular (LV) dysfunction. Transventricular ventricular septal defect (VSD) closure and previous palliation significantly affected LV function and RV size, respectively. Male gender and the transventricular VSD closure were independent predictors for PVR. Conclusions: Male gender and surgical history (palliation, VSD closure approach) significantly affected the long-term outcomes in rToF patients and should be taken into consideration in the follow-up management and in PVR timing in this patient population.
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18
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Ghonim S, Gatzoulis MA, Ernst S, Li W, Moon JC, Smith GC, Heng EL, Keegan J, Ho SY, McCarthy KP, Shore DF, Uebing A, Kempny A, Alpendurada F, Diller GP, Dimopoulos K, Pennell DJ, Babu-Narayan SV. Predicting Survival in Repaired Tetralogy of Fallot: A Lesion-Specific and Personalized Approach. JACC Cardiovasc Imaging 2021; 15:257-268. [PMID: 34656466 PMCID: PMC8821017 DOI: 10.1016/j.jcmg.2021.07.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 07/20/2021] [Accepted: 07/28/2021] [Indexed: 11/24/2022]
Abstract
Objectives This study sought to identify patients with repaired tetralogy of Fallot (rTOF) at high risk of death and malignant ventricular arrhythmia (VA). Background To date there is no robust risk stratification scheme to predict outcomes in adults with rTOF. Methods Consecutive patients were prospectively recruited for late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) to define right and left ventricular (RV, LV) fibrosis in addition to proven risk markers. Results The primary endpoint was all-cause mortality. Of the 550 patients (median age 32 years, 56% male), 27 died (mean follow-up 6.4 ± 5.8; total 3,512 years). Mortality was independently predicted by RVLGE extent, presence of LVLGE, RV ejection fraction ≤47%, LV ejection fraction ≤55%, B-type natriuretic peptide ≥127 ng/L, peak exercise oxygen uptake (V02) ≤17 mL/kg/min, prior sustained atrial arrhythmia, and age ≥50 years. The weighted scores for each of the preceding independent predictors differentiated a high-risk subgroup of patients with a 4.4%, annual risk of mortality (area under the curve [AUC]: 0.87; P < 0.001). The secondary endpoint (VA), a composite of life-threatening sustained ventricular tachycardia/resuscitated ventricular fibrillation/sudden cardiac death occurred in 29. Weighted scores that included several predictors of mortality and RV outflow tract akinetic length ≥55 mm and RV systolic pressure ≥47 mm Hg identified high-risk patients with a 3.7% annual risk of VA (AUC: 0.79; P < 0.001) RVLGE was heavily weighted in both risk scores caused by its strong relative prognostic value. Conclusions We present a score integrating multiple appropriately weighted risk factors to identify the subgroup of patients with rTOF who are at high annual risk of death who may benefit from targeted therapy.
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Affiliation(s)
- Sarah Ghonim
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Michael A Gatzoulis
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Sabine Ernst
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Wei Li
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - James C Moon
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom
| | - Gillian C Smith
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom
| | - Ee Ling Heng
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Jennifer Keegan
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Siew Yen Ho
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Karen P McCarthy
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Darryl F Shore
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Anselm Uebing
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom
| | - Aleksander Kempny
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom
| | - Francisco Alpendurada
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Gerhard P Diller
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom
| | - Konstantinos Dimopoulos
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Dudley J Pennell
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom
| | - Sonya V Babu-Narayan
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; National Heart Lung Institute, Imperial College London, United Kingdom.
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19
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Alsaied T, Geva T, Graf JA, Sleeper LA, Marie Valente A. Biventricular Global Function Index Is Associated With Adverse Outcomes in Repaired Tetralogy of Fallot. Circ Cardiovasc Imaging 2021; 14:e012519. [PMID: 34387102 DOI: 10.1161/circimaging.121.012519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cardiac magnetic resonance (CMR) derived biventricular global function index (BVGFI) is a new CMR parameter that integrates biventricular volumes, mass, and function using clinically available CMR parameters. The associations of BVGFI with clinical outcomes in repaired tetralogy of Fallot are unknown. METHODS Patients with repaired tetralogy of Fallot who had a CMR before the occurrence of a composite outcome of death, resuscitated sudden death, or sustained ventricular tachycardia were studied. BVGFI was calculated as the average of right and left GFI. GFI was defined as (ventricular stroke volume×100)/(ventricular mean cavity volume + total ventricular myocardial volume). Ventricular mean cavity volume was defined as ([end-diastolic + end-systolic volume]/2). Cox multivariable regression analysis and classification and regression tree methodology were used. RESULTS Of the 736 eligible subjects (mean age at CMR 25.4±14.5 years), with a median follow-up of 28 months, 55 subjects (7.4%) reached the composite outcome (46 deaths and 9 sustained ventricular tachycardia). Independent associations with the composite outcome were as follows: BVGFI <37 (hazard ratio, 2.52; P=0.004), right ventricular end-systolic volume index >85 mL/m2 (hazard ratio, 3.25; P<0.001), atrial tachycardia (hazard ratio, 2.03; P=0.021), and age at repair >2.5 years (hazard ratio, 3.37; P<0.001). Classification and regression tree analysis identified BVGFI as the most discriminatory CMR parameter associated with a high risk for adverse outcomes. CONCLUSIONS BVGFI, a novel CMR-derived imaging biomarker combining biventricular volumes, mass, and function, may improve risk stratification for adverse clinical outcomes in patients with repaired tetralogy of Fallot.
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Affiliation(s)
- Tarek Alsaied
- Department of Cardiology. Boston Children's Hospital, Harvard Medical School, MA (T.A., T.G., J.A.G., L.A.S., A.M.V.)
| | - Tal Geva
- Department of Cardiology. Boston Children's Hospital, Harvard Medical School, MA (T.A., T.G., J.A.G., L.A.S., A.M.V.)
| | - Julia A Graf
- Department of Cardiology. Boston Children's Hospital, Harvard Medical School, MA (T.A., T.G., J.A.G., L.A.S., A.M.V.)
| | - Lynn A Sleeper
- Department of Cardiology. Boston Children's Hospital, Harvard Medical School, MA (T.A., T.G., J.A.G., L.A.S., A.M.V.)
| | - Anne Marie Valente
- Department of Cardiology. Boston Children's Hospital, Harvard Medical School, MA (T.A., T.G., J.A.G., L.A.S., A.M.V.).,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.M.V.)
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Pushparajah K, Duong P. Real-Time Exercise Cardiac Magnetic Resonance Imaging in Tetralogy of Fallot: A Tool for Revisiting a Clinical Conundrum. Circ Cardiovasc Imaging 2021; 14:e013209. [PMID: 34384225 DOI: 10.1161/circimaging.121.013209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kuberan Pushparajah
- School of Biomedical Engineering and Imaging Sciences, King's College London (K.P., P.D.).,Department of Paediatric Cardiology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust (K.P.)
| | - Phuoc Duong
- School of Biomedical Engineering and Imaging Sciences, King's College London (K.P., P.D.).,Department of Paediatric Cardiology, Alderhey Children's NHS Foundation Trust (P.D.)
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21
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Lee MG, Yao JV, Binny S, Larobina M, Skillington P, Grigg LE, Zentner D. Long-term outcome of adult survivors of tetralogy of Fallot. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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22
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Kim W, Kwak JG, Kwon HW, Cho S, Kim WH, Lee JR, Min J. Pulmonary valve replacement may not restore ventricular volume and functional status in patients with pulmonary regurgitation after late tetralogy of Fallot repair. Eur J Cardiothorac Surg 2021; 61:64-72. [PMID: 34254142 DOI: 10.1093/ejcts/ezab277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/12/2021] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Clinically, tetralogy of Fallot (TOF) patients who underwent repair late (older than 2 years) appears to have worse outcomes after pulmonary valve replacement than patients who underwent repair early. We proceeded to review the clinical features of late-repaired TOF patients who required pulmonary valve replacement. METHODS Fifty patients who underwent pulmonary valve replacement after TOF repair over the age of 2 years from 2000 to 2018 were retrospectively reviewed. Pre- and postoperative cardiac magnetic resonance imaging, cardiopulmonary exercise tests, and cardiac catheterization were analysed. RESULTS The median age of patients at the time of TOF repair and pulmonary valve replacement was 3.6 and 23.4 years, respectively. The median interval from TOF repair to pulmonary valve replacement was 20.5 years. Cardiac magnetic resonance imaging and cardiopulmonary exercise tests were performed at a median of 5.9 and 3.7 years after pulmonary valve replacement, respectively. Cardiac magnetic resonance revealed that there were significant changes in the indexed values of the right ventricle end-diastolic volume (164.7-106.9 ml/m2, P < 0.001), end-systolic volume (101.4-64.9 ml/m2, P < 0.001), stroke volume (66.8-48.0 ml/m2, P = 0.007) and cardiac output (5.1-3.6 l/m2, P = 0.040). Twenty-eight percentage of patients achieved normalization of the right ventricular volume after pulmonary valve replacement. In the exercise test, the maximum rate of oxygen consumption (72.5-69.5%) and oxygen pulse (95.0-83.0%) changed without statistical significance. CONCLUSIONS Although pulmonary valve replacement after late TOF correction improves right ventricular volume status, only a minority of patients achieve normalization of right ventricular end systolic volume and a normal functional status.
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Affiliation(s)
- Woojung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Hye Won Kwon
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Sungkyu Cho
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Jeong Ryul Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Jooncheol Min
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Republic of Korea
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Detection of persistent systolic and diastolic abnormalities in asymptomatic pediatric repaired tetralogy of Fallot patients with preserved ejection fraction: a CMR feature tracking study. Eur Radiol 2021; 31:6156-6168. [PMID: 33492469 DOI: 10.1007/s00330-020-07643-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 11/23/2020] [Accepted: 12/17/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES A fast cardiovascular magnetic resonance (CMR) feature tracking was applied to assess ventricular systolic and diastolic function. This study sought to detect right ventricular (RV) systolic and diastolic abnormalities in asymptomatic pediatric repaired tetralogy of Fallot (rTOF) patients with preserved RV ejection fraction (EF). METHODS One hundred asymptomatic pediatric rTOF patients with preserved RVEF ≥ 45% and 52 control subjects underwent cine CMR examinations. Tricuspid annular plane systolic excursion (TAPSE); peak tricuspid annular systolic (Sm), early diastolic (Em), and late diastolic (Am) velocities; and biventricular global radial (GRS), circumferential (GCS), and longitudinal strains (GLS) were analyzed using CMR feature tracking. RESULTS TAPSE, Sm, Em, Am, and RV GLS were significantly lower in rTOF patients compared with controls (all p < 0.01). The lower limits (mean-2·standard deviations) of TAPSE, Sm, Em, and Am among controls were 10.9 mm, 6.3 cm/s, 8.9 cm/s, and 2.4 cm/s, respectively, and 78%, 75%, 75%, and 19% of rTOF patients had corresponding measurements below these thresholds. Among rTOF patients, RV GLS was significantly lower in females than in males (p < 0.05). CONCLUSIONS Despite preserved RVEF, there was a high prevalence of RV systolic and diastolic dysfunction among pediatric rTOF patients, which was detected using fast CMR feature tracking. KEY POINTS • There was high prevalence of systolic and diastolic dysfunction in asymptomatic pediatric repaired tetralogy of Fallot (rTOF) patients despite preserved right ventricular (RV) ejection fraction (EF). • Significant correlations were observed between right ventricular (RV) measurements (strains, tricuspid annular plane systolic excursion (TAPSE), peak tricuspid annular early diastolic velocity (Em), peak tricuspid annular late diastolic velocity (Am)), and left ventricular (LV) strain measurements, which indicates ventricular-ventricular interactions at systolic and diastolic function level. • Right ventricular (RV) global longitudinal strain (GLS) was lower in female repaired tetralogy of Fallot (rTOF) patients than in males, suggesting females with rTOF may be at a higher risk of developing RV systolic dysfunction than males.
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Abstract
Over the past decade, cardiovascular magnetic resonance (CMR) has become a mainstream noninvasive imaging tool for assessment of adult and pediatric patients with congenital heart disease. It provides comprehensive anatomic and hemodynamic information that echocardiography and catheterization alone do not provide. Extracardiac anatomy can be delineated with high spatial resolution, intracardiac anatomy can be imaged in multiple planes, and functional assessment can be made accurately and with high reproducibility. In patients with heart failure, CMR provides not only reference standard evaluation of ventricular volumes and function but also information about the possible causes of dysfunction.
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Affiliation(s)
- Vivek Muthurangu
- Institute of Cardiovascular Science, University College London, 30 Guilford Street, London WC1N 1EH, UK.
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Risk Factors for Mortality and Ventricular Tachycardia in Patients With Repaired Tetralogy of Fallot: A Systematic Review and Meta-analysis. Can J Cardiol 2020; 36:1815-1825. [DOI: 10.1016/j.cjca.2020.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/14/2020] [Accepted: 01/28/2020] [Indexed: 12/18/2022] Open
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Mohamed I, Stamm R, Keenan R, Lowe B, Coffey S. Assessment of Disease Progression in Patients With Repaired Tetralogy of Fallot Using Cardiac Magnetic Resonance Imaging: A Systematic Review. Heart Lung Circ 2020; 29:1613-1620. [DOI: 10.1016/j.hlc.2020.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/16/2020] [Indexed: 11/24/2022]
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van den Bosch E, Cuypers JAAE, Luijnenburg SE, Duppen N, Boersma E, Budde RPJ, Krestin GP, Blom NA, Breur HMPJ, Snoeren MM, Roos-Hesselink JW, Kapusta L, Helbing WA. Ventricular response to dobutamine stress cardiac magnetic resonance imaging is associated with adverse outcome during 8-year follow-up in patients with repaired Tetralogy of Fallot. Eur Heart J Cardiovasc Imaging 2020; 21:1039-1046. [PMID: 31596460 PMCID: PMC7440962 DOI: 10.1093/ehjci/jez241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/16/2019] [Accepted: 09/06/2019] [Indexed: 11/15/2022] Open
Abstract
AIMS The aim of this study was to evaluate the possible value of dobutamine stress cardiac magnetic resonance imaging (CMR) to predict adverse outcome in Tetralogy of Fallot (TOF) patients. METHODS AND RESULTS In previous prospective multicentre studies, TOF patients underwent low-dose dobutamine stress CMR (7.5 µg/kg/min). Subsequently, during regular-care patient follow-up, patients were assessed for reaching the composite endpoint (cardiac death, arrhythmia-related hospitalization, or cardioversion/ablation, VO2 max ≤65% of predicted). A normal stress response was defined as a decrease in end-systolic volume (ESV) and increase in ejection fraction. The relative parameter change during stress was calculated as relative parameter change = [(parameterstress - parameterrest)/parameterrest] * 100. The predictive value of dobutamine stress CMR for the composite endpoint was determined using time-to-event analyses (Kaplan-Meier) and Cox proportional hazard analysis. We studied 100 patients [67 (67%) male, median age at baseline CMR 17.8 years (interquartile range 13.5-34.0), age at TOF repair 0.9 years (0.6-2.1)]. After a median follow-up of 8.6 years (6.7-14.1), 10 patients reached the composite endpoint. An abnormal stress response (30% vs. 4.4%, P = 0.021) was more frequently observed in composite endpoint patients. Also in endpoint patients, the relative decrease in right ventricular ESV decreased less during stress compared with the patients without an endpoint (-17 ± 15 vs. -26 ± 13 %, P = 0.045). Multivariable analyses identified an abnormal stress response (hazard ratio 10.4; 95% confidence interval 2.5-43.7; P = 0.001) as predictor for the composite endpoint. CONCLUSION An abnormal ventricular response to dobutamine stress is associated with adverse outcome in patients with repaired TOF.
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Affiliation(s)
- Eva van den Bosch
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3000 CM Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.,Netherlands Heart Institute, Moreelsepark 1, 3511 EP Utrecht, The Netherlands
| | - Judith A A E Cuypers
- Department of Cardiology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Saskia E Luijnenburg
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3000 CM Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Nienke Duppen
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3000 CM Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Gabriel P Krestin
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Hans M P J Breur
- Division of Pediatric Cardiology, Department of Pediatrics, University Medical Centre Utrecht, Lundlaan 6, 3508 AB Utrecht, The Netherlands
| | - Miranda M Snoeren
- Department of Radiology, Radboud University Medical Center, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Livia Kapusta
- Division of Pediatric Cardiology, Department of Pediatrics, Tel Aviv Sourasky Medical Centre, Sackler School of Medicine, Tel Aviv University, Weizmann street, 64239 Tel Aviv, Israel.,Division of Pediatric Cardiology, Department of Pediatrics, Radboud University Medical Center, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - Willem A Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3000 CM Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Radboud University Medical Center, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
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Egbe AC, Connolly HM, Miranda WR, Scott CG, Borlaug BA. Prognostic implications of inferior vena cava haemodynamics in ambulatory patients with tetralogy of Fallot. ESC Heart Fail 2020; 7:2589-2596. [PMID: 32588556 PMCID: PMC7524124 DOI: 10.1002/ehf2.12836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/21/2020] [Accepted: 05/29/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS Right atrial pressure (RAP) provides a composite measure of right ventricular diastolic dysfunction, right atrial compliance, and volume status, and these three variables are typically abnormal in adults with repaired tetralogy of Fallot (TOF). RAP is a well-established prognostic metric in patients with pulmonary hypertension, and recent data suggest that RAP is associated with clinical outcomes in TOF. The purpose of this study was to determine the role of inferior vena cava (IVC) haemodynamics (size and collapsibility) for the assessment of RAP and its potential application for risk stratification and prognostication in the TOF population. METHODS AND RESULTS Adult TOF patients with echocardiographic assessment of IVC haemodynamics were divided into patients with (derivation cohort, n = 256) and without (validation cohort, n = 492) cardiac catheterization data. We assessed the correlation between IVC haemodynamics, RAP, and disease severity indices [arrhythmias, peak oxygen consumption (VO2 ), and heart failure hospitalization] in derivation cohort and compared it with the correlations in the validation cohort. IVC haemodynamics correlated with RAP (r = 0.52, P < 0.001), with disease severity indices {atrial arrhythmias [area under the curve (AUC) 0.81], ventricular arrhythmias [AUC 0.67], heart failure hospitalizations [AUC 0.78], and peak VO2 [r = 0.53]}, and with transplant-free survival in the derivation cohort. Similar correlations between IVC haemodynamics, disease severity indices, and transplant-free survival were also observed in the validation cohort. CONCLUSIONS These findings suggest that IVC haemodynamics can potentially be used for risk stratification and prognostication in TOF patients and can complement the current risk models that are based predominately on right ventricular volumes and systolic function.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Hock J, Schwall L, Pujol C, Hager A, Oberhoffer R, Ewert P, Tutarel O. Tetralogy of Fallot or Pulmonary Atresia with Ventricular Septal Defect after the Age of 40 Years: A Single Center Study. J Clin Med 2020; 9:jcm9051533. [PMID: 32438748 PMCID: PMC7290291 DOI: 10.3390/jcm9051533] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/17/2022] Open
Abstract
Background: The population of adults with tetralogy of Fallot (TOF) or pulmonary atresia with ventricular septal defect (PA/VSD) is growing and aging. Data regarding older patients are scarce. Prognostic outcome parameters in adults with TOF or PA/VSD ≥ 40 years were studied. Methods: This was a retrospective study of patients ≥ 40 years of age during the study period (January 2005–March 2018). Major adverse cardiac events (MACE) were a combined primary endpoint including death from any cause, prevented sudden cardiac death, pacemaker implantation, arrhythmia, and new-onset heart failure. Additionally, MACE II (secondary endpoint) was a combination of death from any cause and prevented sudden cardiac death. Results: 184 (58.7% female, mean age 45.3 ± 7.2 years) patients were included (159 (86.4%) TOF and 25 (13.6%) PA/VSD). During a median follow-up of 3.1 years (IQR: 0.6–6.5), MACE occurred in 35 and MACE II in 13 patients. On multivariable analysis, New York Heart Association class [HR: 2.1, 95% CI: 1.2–3.6, p = 0.009] emerged as an independent predictor for MACE, and age at corrective surgery [HR: 13.2, 95% CI: 1.6–107.1, p = 0.016] for MACE II. Conclusions: Adults with TOF or PA/VSD ≥ 40 years are burdened with significant morbidity and mortality. New York Heart Association class and age at corrective surgery were independent predictors of outcome.
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Affiliation(s)
- Julia Hock
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, Technical University of Munich, 80636 Munich, Germany; (J.H.); (L.S.); (C.P.); (A.H.); (P.E.)
- Institute of Preventive Paediatrics, Department of Sport and Health Sciences, Technical University of Munich, 80992 Munich, Germany;
| | - Laurent Schwall
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, Technical University of Munich, 80636 Munich, Germany; (J.H.); (L.S.); (C.P.); (A.H.); (P.E.)
| | - Claudia Pujol
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, Technical University of Munich, 80636 Munich, Germany; (J.H.); (L.S.); (C.P.); (A.H.); (P.E.)
| | - Alfred Hager
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, Technical University of Munich, 80636 Munich, Germany; (J.H.); (L.S.); (C.P.); (A.H.); (P.E.)
| | - Renate Oberhoffer
- Institute of Preventive Paediatrics, Department of Sport and Health Sciences, Technical University of Munich, 80992 Munich, Germany;
| | - Peter Ewert
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, Technical University of Munich, 80636 Munich, Germany; (J.H.); (L.S.); (C.P.); (A.H.); (P.E.)
| | - Oktay Tutarel
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, Technical University of Munich, 80636 Munich, Germany; (J.H.); (L.S.); (C.P.); (A.H.); (P.E.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80992 Munich, Germany
- Correspondence: ; Tel.: +49–89–1218–2729
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Impact of Inferior Venae Cava Assessment in Tetralogy of Fallot. CJC Open 2020; 2:129-134. [PMID: 32462126 PMCID: PMC7242499 DOI: 10.1016/j.cjco.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/16/2020] [Indexed: 11/23/2022] Open
Abstract
Background Inferior vena cava (IVC) size and collapsibility provide a noninvasive estimate of right heart filling pressures, an important determinant of right heart hemodynamic performance that is not measured by cardiac magnetic resonance imaging (CMRI). We hypothesized that compared with CMRI risk model alone, a combined CMRI-IVC risk model will have better correlation with disease severity and peak oxygen consumption in patients with tetralogy of Fallot (TOF). Methods We performed a retrospective review of patients with TOF with moderate/severe pulmonary regurgitation who underwent CMRI and echocardiography. A CMRI risk model was constructed using right ventricular (RV) end-diastolic volume index, RV end-systolic volume index, RV ejection fraction, and left ventricular ejection fraction. We added IVC hemodynamic classification to the CMRI indices to create CMRI-IVC risk model, and IVC hemodynamics were modeled as a categorical variable: normal vs mild/moderately abnormal (dilated IVC or reduced collapsibility) vs severely abnormal IVC hemodynamics (dilated IVC and reduced collapsibility). We defined disease severity as atrial arrhythmias, ventricular arrhythmias, and heart failure hospitalization. Results Of 207 patients, 131 (63%), 72 (35%), and 4 (2%) had normal, mild/moderately abnormal, and severely abnormal IVC hemodynamics, respectively. Compared with the CMRI risk model, the CMRI-IVC risk model had a better correlation with disease severity (area under the curve, 0.62; 95% confidence interval, 0.51-0.74 vs area under the curve 0.84, 95% confidence interval, 0.78-0.91, P = 0.006) and peak oxygen consumption (r = 0.35, P = 0.042 vs r = 0.43, P = 0.031, Meng test P = 0.026). Conclusions The combined CMRI-IVC risk model had a better correlation with disease severity compared with CMRI indices alone and can potentially improve risk stratification in the population with TOF.
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Kauw D, Woudstra OI, van Engelen K, Meijboom FJ, Mulder BJM, Schuuring MJ, Bouma BJ. 22q11.2 deletion syndrome is associated with increased mortality in adults with tetralogy of Fallot and pulmonary atresia with ventricular septal defect. Int J Cardiol 2020; 306:56-60. [PMID: 32145937 DOI: 10.1016/j.ijcard.2020.02.064] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/15/2020] [Accepted: 02/26/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND 22q11.2 Deletion syndrome (22q11.2DS) is common in patients with tetralogy of Fallot (TOF) or pulmonary atresia with ventricular septal defect (PA/VSD) and is associated with worse outcomes in children. Whether this impaired prognosis is also translated into adulthood is unknown, as data in adult patients are limited. We aimed to compare long-term outcomes in adults with TOF or PA/VSD both with and without 22q11.2DS. METHODS This study prospectively followed a nationwide multicenter cohort of TOF or PA/VSD patients with genetically confirmed presence or absence of 22q11.2DS, from inclusion in the Dutch national CONCOR registry for adults with congenital heart disease (CHD) onward. Outcome measures included all-cause mortality, cardiac mortality, need for pulmonary valve replacement (PVR), ventricular arrhythmias (VA), pacemaker implantation, and ICD implantation. RESULTS In total, 479 patients were included (277 (58%) male, median age 28 [IQR; 21-37] years, 62 (13%) with PA/VSD, 34 (7%) with 22q11.2DS). During a median follow-up of 11 [IQR; 6-13] years, 52 (11%) patients died (8 with 22q11.2DS and 44 without 22q11.2DS). Patients with 22q11.2DS had significant decreased survival after 12 years (76% [95% CI; 62-93]) compared to patients without 22q11.2DS (89% [95% CI; 86-92], p = 0.008). 22q11.2DS was associated with increased risk of all-cause mortality and cardiac-mortality, independent of age, sex, and PA/VSD. No association was found between 22q11.2DS and late complications i.e. PVR, VA, pacemaker, or ICD implantation. CONCLUSIONS Adults with TOF or PA/VSD with 22q11.2DS have a significantly worse survival than adults without this deletion. In patients with TOF or PA/VSD, genetic analysis for the presence of 22q11.2DS is important for risk stratification and genetic counseling.
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Affiliation(s)
- Dirkjan Kauw
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3351, EP, Utrecht, the Netherlands
| | - Odilia I Woudstra
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Klaartje van Engelen
- Department of Clinical Genetics, Amsterdam UMC, VU University Medical Centre, De Boelelaan 1117, 1081, HV, Amsterdam, the Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Mark J Schuuring
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Department of Cardiology, Haga Teaching Hospital, Els-Borst-Eilersplein 275, 2545 AA the Hague, the Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
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Preprocedural Imaging Evaluation of Pulmonary Valve Replacement After Repair of Tetralogy of Fallot: What the Radiologist Needs to Know. J Thorac Imaging 2020; 35:153-166. [PMID: 32073541 DOI: 10.1097/rti.0000000000000478] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Tetrallogy of Fallot (TOF) is the most frequent form of cyanotic congenital heart disease. Despite advances in surgical and medical treatment, mortality remains high. Residual dysfunction of the pulmonary valve (PV) after correction of right ventricular outflow tract obstruction is an important cause of morbidity, leading to irreversible right ventricular dysfunction, arrhythmias, heart failure and occasionally, death. The strategies for PVR have evolved over the last decades, and the timing of the intervention remains the foundation of the decision-making process. Symptoms of heart failure are unreliable indicators for optimal timing of repair. Imaging plays an essential role in the assessment of PV integrity and dysfunction. The identification of the best timing for PVR requires a multimodality approach. Transthoracic echocardiography is the most commonly used imaging modality for the initial assessment and follow-up of TOF patients, although its utility has technical limitations, especially in adults. Cardiac computed tomography and magnetic resonance imaging are now routinely used for preoperative and postoperative evaluation of these patients, and provide highly valuable information about the anatomy and pathophysiology. Imaging evidence of disease progression is now part of the major guidelines to define the best timing for reintervention. The purpose of this article is to review the pathophysiology after TOF repair, identify the main imaging anatomic and physiologic features, describe the indications for PVR and recognize the role of imaging in the assessment of these patients to define the appropriate timing of PVR.
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Timing of Repair in Tetralogy of Fallot: Effects on Outcomes and Myocardial Health. Cardiol Rev 2020; 29:62-67. [PMID: 31934899 DOI: 10.1097/crd.0000000000000293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Early complete repair of tetralogy of Fallot (ToF) prior to 1 year of age has been demonstrated to be safe and has survival benefits over late repair. The age at repair of ToF affects long-term outcomes. This may largely be related to preserved, or comparatively better, myocardial health. Most studies advocate for an age of repair between 3 and 6 months and certainly below the age of 1 year. Patients with severe right ventricular outflow tract obstruction represent an exception to this rule and may require neonatal repair or surgical and catheter-based palliation before surgery. Older age at repair beyond the first birthday leads to unfavorable right ventricular remodeling with increased right ventricular stiffness and hypertrophy and is associated with increased long-term ventricular tachycardia and all-cause mortality. In this article, we review the short- and long-term benefits of early repair, with a focus on long-term morbidity. In conclusion, we emphasize the importance of myocardial health and the relationship to early repair and advocate for the use of magnetic resonance imaging in adult patients with repaired ToF to detect myocardial fibrosis.
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Egbe AC, Pellikka PA, Afzal A, Jain V, Thotamgari S, Miranda WR, Connolly HM. Prognostic Implications of Left Ventricular Cardiomyopathy in Adults With Tetralogy of Fallot. CJC Open 2020; 2:1-7. [PMID: 32159130 PMCID: PMC7063625 DOI: 10.1016/j.cjco.2019.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Despite the significant risk of cardiovascular mortality after tetralogy of Fallot (TOF) repair, there are limited data about left ventricular (LV) cardiomyopathy in this population, thus creating important knowledge gaps. This study aims to address some of these knowledge gaps by describing the risk and prognostic implications of LV systolic dysfunction (LVD) after TOF repair. METHODS We performed a cohort study of adult patients after TOF repair with an echocardiographic assessment of LV ejection fraction (LVEF) to determine the association between LVD and cardiovascular events, defined as sustained ventricular tachycardia, aborted sudden death, heart transplantation, or death. Prevalent and incidence LVD were defined as LVEF < 50% at baseline or new decrease in LVEF to < 50% during follow-up, respectively. RESULTS Of 574 patients (age 38 ± 13 years), the baseline LVEF was 57% ± 9% and 68 (12%) had prevalent LVD. Cardiovascular events occurred in 126 patients (22%) during 10.5 ± 6.2 years of follow-up. LVEF was an independent predictor of mortality (hazard ratio, 1.16; 95% confidence interval, 1.16-1.24; P = 0.003) per 5%-point decrease in LVEF. Among the 357 patients with preserved LVEF and echocardiographic follow-up, incident LVD occurred in 23 (6%) during 3.8 ± 1.6 years of follow-up. Event-free survival was significantly lower in patients with incident LVD compared with patients without incident LVD (87% vs 71%, P = 0.021). CONCLUSION Prevalent and incident LVD occurred in 12% and 6% of this cohort, respectively, and were associated with lower event-free survival. Incident LVD suggests the presence of subclinical LV cardiomyopathy, and further studies are required to determine optimal strategies for diagnosing and treating subclinical LV cardiomyopathy to improve outcomes in the population with TOF.
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Affiliation(s)
- Alexander C. Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Egbe AC, Adigun R, Anand V, West CP, Montori VM, Murad HM, Akintoye E, Osman K, Connolly HM. Left Ventricular Systolic Dysfunction and Cardiovascular Outcomes in Tetralogy of Fallot: Systematic Review and Meta-analysis. Can J Cardiol 2019; 35:1784-1790. [DOI: 10.1016/j.cjca.2019.07.634] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/27/2019] [Accepted: 07/27/2019] [Indexed: 12/11/2022] Open
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Robinson Vimala L, Hanneman K, Thavendiranathan P, Nguyen ET, Silversides CK, Wald RM. Characteristics of Cardiovascular Magnetic Resonance Imaging and Outcomes in Adults With Repaired Truncus Arteriosus. Am J Cardiol 2019; 124:1636-1642. [PMID: 31540664 DOI: 10.1016/j.amjcard.2019.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
The cardiovascular magnetic resonance imaging (CMR) features of adults with repaired truncus arteriosus (rTA) are largely undefined. We sought to explore CMR characteristics in rTA and to identify associations between imaging findings and cardiovascular outcomes. Adults with rTA and CMR were identified and anatomic subtypes (1-4) were assigned (Collett and Edwards classification). CMR characteristics, clinical data at last follow-up and adverse cardiovascular outcome were recorded. Twenty-seven adults (19% male) were studied (median age at cardiovascular magnetic resonance 26 years [interquartile range 18 to 40]) over 5.2-year duration [interquartile range 2.5 to 7.5]. With the exception of mildly increased RV mass (30 ± 12 g/m2), cardiac chamber measurements were within the normal range. In CMR measurements, only pulmonary artery peak velocity differed in subtypes (highest in subtype 3, 318 ± 26 cm/s, p = 0.029). Number of cardiovascular interventions in adulthood was moderately correlated with left ventricular end-diastolic volume (r = 0.463, p = 0.015), left ventricular ejection fraction (r = 0.425, p = 0.027) and neoaortic root size (r = 0.398, p = 0.039). Cardiovascular events (nonmutually exclusive) in 5 of 27 patients (19%) included death (n = 1), heart failure (n = 1), ventricular tachycardia (n = 1), and atrial tachycardia (n = 3). Increased cardiovascular risk was associated with decreased right ventricular ejection fraction (odds ratio 1.153, confidence interval 1.003 to 1.326, p = 0.046) and smaller ascending aorta diameter (odds ratio 1.758, confidence interval 1.037 to 2.976, p = 0.036). In conclusion, decreased right ventricular ejection fraction and smaller ascending aorta on cardiovascular magnetic resonance were associated with adverse events in rTA.
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Egbe AC, Banala K, Vojjini R, Osman K, Afzal A, Jain V, Thotamgari S, Ammash NM. The applications and potential limitations of right ventricular volumes as surrogate marker in tetralogy of fallot. IJC HEART & VASCULATURE 2019; 26:100430. [PMID: 31763442 PMCID: PMC6864123 DOI: 10.1016/j.ijcha.2019.100430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/03/2019] [Accepted: 10/06/2019] [Indexed: 11/17/2022]
Abstract
Cardiac magnetic resonance imaging derived right ventricular (RV) volumes are often necessary for optimal timing of pulmonary valve replacement in patients with tetralogy of Fallot (TOF). This practice is based on previous studies that reported preoperative RV volumetric thresholds that predicted postoperative RV remodeling. As a result, pulmonary valve replacements are being performed even in asymptomatic patients based on RV volumetric thresholds that predict complete postoperative RVOT remodeling. Hence, RV volumes are now being used as surrogate markers/endpoints for future cardiovascular outcomes. Unfortunately, there are no studies showing survival benefit for performing pulmonary valve replacement at smaller RV volumes. This review underscores some of the limitations of using RV volumes as surrogate markers for clinical outcomes, and also highlights knowledge gaps about the pathophysiologic mechanism of cardiovascular death in the TOF population.
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Affiliation(s)
- Alexander C. Egbe
- Corresponding author at: Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, United States.
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CMR feature tracking left ventricular strain-rate predicts ventricular tachyarrhythmia, but not deterioration of ventricular function in patients with repaired tetralogy of Fallot. Int J Cardiol 2019; 295:1-6. [DOI: 10.1016/j.ijcard.2019.07.097] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 11/18/2022]
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Right ventricular systolic dysfunction but not dilatation correlates with prognostically significant reductions in exercise capacity in repaired Tetralogy of Fallot. Eur Heart J Cardiovasc Imaging 2019; 21:906-913. [DOI: 10.1093/ehjci/jez245] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/28/2019] [Accepted: 09/11/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
The optimal timing for pulmonary valve replacement in asymptomatic patients with repaired Tetralogy of Fallot (rTOF) and pulmonary regurgitation remains uncertain but is often guided by increases in right ventricular (RV) end-diastolic volume. As cardiopulmonary exercise testing (CPET) performance is a strong prognostic indicator, we assessed which cardiovascular magnetic resonance (CMR) parameters correlate with reductions in exercise capacity to potentially improve identification of high-risk patients.
Methods and results
In all, 163 patients with rTOF (mean age 24.5 ± 10.2 years) who had previously undergone CMR and standardized CPET protocols were included. The indexed right and left ventricular end-diastolic volumes (RVEDVi, LVEDVi), right and left ventricular ejection fractions (RVEF, LVEF), indexed RV stroke volume (RVSVi), and pulmonary regurgitant fraction (PRF) were quantified by CMR and correlated with CPET-determined peak oxygen consumption (VO2) or peak work. On univariable analysis, there was no significant correlation between RVEDVi and PRF with peak VO2 or peak work (% Jones-predicted). In contrast, RVEF and RVSVi had significant correlations with both peak VO2 and peak work that remained significant on multivariable analysis. For a previously established prognostic peak VO2 threshold of <27 mL/kg/min, receiver-operating characteristic curve analysis demonstrated a Harrell’s c of 0.70 for RVEF (95% confidence interval 0.61–0.79) with a sensitivity of 88% for RVEF <40%.
Conclusion
In rTOF, CMR indices of RV systolic function are better predictors of CPET performance than RV size. An RVEF <40% may be useful to identify prognostically significant reductions in exercise capacity in patients with varying degrees of RV dilatation.
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Egbe AC, Vallabhajosyula S, Vojjini R, Banala K, Najam M, Faizee F, Khalil F, Ullah MW, Deshmukh AJ. Prevalence and in-hospital mortality during arrhythmia-related admissions in adults with tetralogy of Fallot. Int J Cardiol 2019; 297:49-54. [PMID: 31604657 DOI: 10.1016/j.ijcard.2019.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/18/2019] [Accepted: 09/04/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although outcomes of arrhythmia diagnosis have been described in ambulatory tetralogy of Fallot (TOF) patients, these have not been studied in hospitalized patients. The purpose of this study was to determine the prevalence and in-hospital mortality due to arrhythmias in TOF patients based on a review of the National Inpatient Sample database. METHODS Admissions in adult TOF patients (2000-2014) were categorized as arrhythmia-related admission (ARA) or non-arrhythmia-related admission (NRA) based on arrhythmia diagnostic codes. RESULTS Of 18,353 admissions, 5071 (27.6%) were ARA. The most common arrhythmias were atrial fibrillation (15.5%), atrial flutter (8.4%) and ventricular tachycardia (8.2%), and the prevalence of overall ARA as well as specific arrhythmia types increased over time. In-hospital mortality for ARA was 5.4%, and decreased over time. Arrhythmia diagnosis was an independent predictor of in-hospital mortality (odds ratio [OR] 1.63, 1.34-2.01, p = 0.001). Similarly, atrial fibrillation (OR 1.49, 1.18-1.89, p = 0.001) and ventricular tachycardia (OR: 2.01, 1.55-2.98, p = 0.001) were independent predictors of in-hospital mortality. Compared to small bed-size hospital, ARA in large hospital bed-size hospital was associated with a lower in-hospital mortality (OR 0.71, 0.53-0.96, p = 0.03). CONCLUSION Atrial fibrillation was the most common arrhythmia in hospitalized TOF patients, and arrhythmia diagnosis (specifically atrial fibrillation and ventricular tachycardia) was an independent predictor of in-hospital mortality, while admission to a large bed-size hospital was associated with a lower risk of in-hospital mortality. Further studies are required to determine if a more proactive approach to arrhythmia management in the ambulatory TOF population will reduce hospitalizations and mortality.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America.
| | | | - Rahul Vojjini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Keerthana Banala
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Maria Najam
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Faizan Faizee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Fouad Khalil
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Muhammad Wajih Ullah
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Abhishek J Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
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Andrade AC, Jerosch‐Herold M, Wegner P, Gabbert DD, Voges I, Pham M, Shah R, Hedderich J, Kramer H, Rickers C. Determinants of Left Ventricular Dysfunction and Remodeling in Patients With Corrected Tetralogy of Fallot. J Am Heart Assoc 2019; 8:e009618. [PMID: 31474177 PMCID: PMC6755839 DOI: 10.1161/jaha.118.009618] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background The aim of this study was to identify in asymptomatic patients with repaired tetralogy of Fallot the prevalence and determinants of impaired left‐sided cardiac function and adverse ventricular remodeling and the relation of left ventricular (LV) dysfunction and remodeling with cardiopulmonary exercise capacity. Methods and Results In a cross‐sectional study, 103 patients with tetralogy of Fallot (median age, 16.3 years) in New York Heart Association class 1, with surgical repair at a median age of 1.1 years, and 63 age‐matched controls were studied. LV, right ventricular function and geometry, LV myocardial extracellular volume (n=57), and left atrial function were quantified with cardiac magnetic resonance. Peak oxygen consumption was measured by a standardized cardiopulmonary exercise test (n=70). Patients with tetralogy of Fallot had lower LV ejection fraction (P=0.001; 49% below age‐adjusted fifth percentile for controls), lower LV mass index (P=0.003), lower LV mass/volume ratio (P<0.01), and impaired left atrial function. Right ventricular mass/volume ratio was the best predictor for LV systolic dysfunction and for a lower LV mass/volume ratio. Compared with controls, LV extracellular volume was higher (P<0.001), particularly in female patients, and associated with subnormal peak oxygen consumption (P=0.037). A peak oxygen consumption below the third percentile reference level was more likely with decreasing LV ejection fraction (P=0.008), and lower LV mass index (P=0.024), but independent of right ventricular ejection fraction. Conclusions In New York Heart Association class 1 patients with tetralogy of Fallot, frequent impaired systolic and diastolic LV function, LV adverse remodeling with LV atrophy, a decreased mass/volume ratio, and extracellular matrix expansion suggest cardiomyopathic changes. The best predictor for LV systolic dysfunction was the right ventricular mass/volume ratio. The subnormal peak oxygen consumption indicates that monitoring of LV status may be important for long‐term prognosis.
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Affiliation(s)
- Ana Cristina Andrade
- Heart InstituteMedical School of São Paulo UniversitySão PauloBrazil
- Department of Congenital Heart Disease and Pediatric CardiologyUniversity Hospital of Schleswig‐HolsteinKielGermany
| | | | - Philip Wegner
- Department of Congenital Heart Disease and Pediatric CardiologyUniversity Hospital of Schleswig‐HolsteinKielGermany
| | - Dominik Daniel Gabbert
- Department of Congenital Heart Disease and Pediatric CardiologyUniversity Hospital of Schleswig‐HolsteinKielGermany
| | - Inga Voges
- Department of Congenital Heart Disease and Pediatric CardiologyUniversity Hospital of Schleswig‐HolsteinKielGermany
| | - Minh Pham
- Department of Congenital Heart Disease and Pediatric CardiologyUniversity Hospital of Schleswig‐HolsteinKielGermany
| | - Ravi Shah
- Department of RadiologyBrigham & Women's Hospital and Harvard Medical SchoolBostonMA
| | - Jürgen Hedderich
- Department for Medical Informatics and StatisticsUniversity Hospital of Schleswig‐HolsteinKielGermany
| | - Hans‐Heiner Kramer
- Department of Congenital Heart Disease and Pediatric CardiologyUniversity Hospital of Schleswig‐HolsteinKielGermany
| | - Carsten Rickers
- University Heart CenterAdult with Congenital Heart Disease UnitUniversity Hospital Hamburg‐EppendorfHamburgGermany
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Prevention of sudden cardiac death in patients with Tetralogy of Fallot: Risk assessment and long term outcome. Int J Cardiol 2018; 269:91-96. [DOI: 10.1016/j.ijcard.2018.06.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/27/2018] [Indexed: 11/22/2022]
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Beurskens NEG, Hagdorn QAJ, Gorter TM, Berger RMF, Vermeulen KM, van Melle JP, Ebels TE, Lui GK, Ceresnak SR, Chan FP, Willems TP. Risk of cardiac tachyarrhythmia in patients with repaired tetralogy of Fallot: a multicenter cardiac MRI based study. Int J Cardiovasc Imaging 2018; 35:143-151. [PMID: 30094564 DOI: 10.1007/s10554-018-1435-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/02/2018] [Indexed: 11/24/2022]
Abstract
Cardiac tachyarrhythmias are the leading cause of morbidity and mortality in patients with repaired tetralogy of Fallot (TOF). We evaluated risk factors for sustained ventricular tachyarrhythmia (VT) and atrial tachyarrhythmia (ATA) in these patients. Patients (n = 319) who underwent cardiac magnetic resonance (CMR) imaging at two tertiary centers between 2007 and 2016 were assessed. Potential risk markers, based on history, cardiac magnetic resonance imaging (CMR), electrocardiography (ECG) and echocardiography, were analyzed for prediction of the primary endpoint of VT, and the secondary endpoint of ATA. During a follow-up of 3.5 (0.9-6.1) years, 20 (6.3%) patients reached the primary endpoint, and 30 (9.4%) the secondary endpoint. Multivariable cox hazards regression identified right ventricular (RV) end-diastolic volume (Hazard ratio [HR] 2.03, per 10 ml/m2 increase; p = 0.02), RV end-systolic volume (HR 3.04, per 10 ml/m2 increase; p = 0.04), RV mass (HR 1.88, per 10 g/m2 increase; p = 0.02), and RV ejection fraction (HR 6.06, per 10% decrease; p = 0.02) derived from CMR to be independent risk factors of VT. In addition, QRS-duration (HR 1.70, per 10 ms increase; p = 0.001) and body mass index (BMI: HR 1.8, per 5 kg/m2 increase; p = 0.02) were independent markers of VT. Older age at TOF repair (HR 1.33, per 2 months increase; p = 0.03) and BMI (HR 1.76, per 5 kg/m2 increase; p < 0.001) independently predicted ATA. RV systolic dysfunction, hypertrophy and dilatation on CMR, together with QRS prolongation, and obesity are predictive of VT in TOF patients. Older age at TOF repair and obesity were associated with the occurrence of ATA.
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Affiliation(s)
- Niek E G Beurskens
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Quint A J Hagdorn
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thomas M Gorter
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karin M Vermeulen
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Tjark E Ebels
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - George K Lui
- Departments of Medicine and Pediatrics, Divisions of Cardiovascular Medicine and Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Scott R Ceresnak
- Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Frandics P Chan
- Department of Radiology, Stanford University Medical Center, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tineke P Willems
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Armenian SH, Rinderknecht D, Au K, Lindenfeld L, Mills G, Siyahian A, Herrera C, Wilson K, Venkataraman K, Mascarenhas K, Tavallali P, Razavi M, Pahlevan N, Detterich J, Bhatia S, Gharib M. Accuracy of a Novel Handheld Wireless Platform for Detection of Cardiac Dysfunction in Anthracycline-Exposed Survivors of Childhood Cancer. Clin Cancer Res 2018; 24:3119-3125. [DOI: 10.1158/1078-0432.ccr-17-3599] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/15/2018] [Accepted: 03/06/2018] [Indexed: 11/16/2022]
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Stewart MH, Macicek SL, Morin DP. Implantable Cardioverter-defibrillators in Adult Congenital Heart Disease. J Innov Card Rhythm Manag 2018; 9:3172-3181. [PMID: 32494493 PMCID: PMC7252815 DOI: 10.19102/icrm.2018.090601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/29/2017] [Indexed: 11/30/2022] Open
Abstract
With improved surgical techniques and medical therapies, many patients who are born with complex congenital heart defects are now living well into adulthood. As these patients age, an increasingly common cause of mortality is sudden cardiac death (SCD) from ventricular tachyarrhythmias. The implantable cardioverter-defibrillator (ICD) is a therapy with the ability to prevent some of these deaths; however, there are many diagnostic and technical challenges that remain in the congenital heart disease (CHD) population. We performed a literature review, searching PubMed for articles that examined the role of ICDs in CHD. We herein present the evidence for when to place an ICD in CHD patients, stratified by subtype as relevant. Then, we discuss the technical challenges and complications that are unique to this patient population. We conclude that, despite active work in the area, more research is needed given the small event rates and clinical variability within CHD populations.
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Affiliation(s)
- Merrill H Stewart
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Scott L Macicek
- Department of Pediatric Cardiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Daniel P Morin
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, USA.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA
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Sjöberg P, Bidhult S, Bock J, Heiberg E, Arheden H, Gustafsson R, Nozohoor S, Carlsson M. Disturbed left and right ventricular kinetic energy in patients with repaired tetralogy of Fallot: pathophysiological insights using 4D-flow MRI. Eur Radiol 2018; 28:4066-4076. [PMID: 29666995 PMCID: PMC6132722 DOI: 10.1007/s00330-018-5385-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/09/2018] [Accepted: 02/13/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Indications for pulmonary valve replacement (PVR) in patients with pulmonary regurgitation (PR) after repaired tetralogy of Fallot (rToF) are debated. We aimed to compare right (RV) and left ventricular (LV) kinetic energy (KE) measured by 4D-flow magnetic resonance imaging (MRI) in patients to controls, to further understand the pathophysiological effects of PR. METHODS Fifteen patients with rToF with PR > 20% and 14 controls underwent MRI. Ventricular volumes and KE were quantified from cine MRI and 4D-flow, respectively. Lagrangian coherent structures were used to discriminate KE in the PR. Restrictive RV physiology was defined as end-diastolic forward flow. RESULTS LV systolic peak KE was lower in rToF, 2.8 ± 1.1 mJ, compared to healthy volunteers, 4.8 ± 1.1 mJ, p < 0.0001. RV diastolic peak KE was higher in rToF (7.7 ± 4.3 mJ vs 3.1 ± 1.3 mJ, p = 0.0001) and the difference most pronounced in patients with non-restrictive RV physiology. KE was primarily located in the PR volume at the time of diastolic peak KE, 64 ± 17%. CONCLUSION This is the first study showing disturbed KE in patients with rToF and PR, in both the RV and LV. The role of KE as a potential early marker of ventricular dysfunction to guide intervention needs to be addressed in future studies. KEY POINTS • Kinetic energy (KE) reflects ventricular performance • KE is a potential marker of ventricular dysfunction in Fallot patients • KE is disturbed in both ventricles in patients with tetralogy of Fallot • KE contributes to the understanding of the pathophysiology of pulmonary regurgitation • Lagrangian coherent structures enable differentiation of ventricular inflows.
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Affiliation(s)
- Pia Sjöberg
- Department of Clinical Sciences, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden.
| | - Sebastian Bidhult
- Department of Clinical Sciences, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden.,Department of Biomedical Engineering, Faculty of Engineering, Lund University, Lund, Sweden
| | - Jelena Bock
- Department of Clinical Sciences, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Einar Heiberg
- Department of Clinical Sciences, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden.,Department of Biomedical Engineering, Faculty of Engineering, Lund University, Lund, Sweden.,Center for Mathematics, Faculty of Engineering, Lund University, Lund, Sweden
| | - Håkan Arheden
- Department of Clinical Sciences, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Ronny Gustafsson
- Department of Clinical Sciences, Cardiothoracic Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Shahab Nozohoor
- Department of Clinical Sciences, Cardiothoracic Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Marcus Carlsson
- Department of Clinical Sciences, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
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Bokma JP, Winter MM, van Dijk AP, Vliegen HW, van Melle JP, Meijboom FJ, Post MC, Berbee JK, Boekholdt SM, Groenink M, Zwinderman AH, Mulder BJ, Bouma BJ. Effect of Losartan on Right Ventricular Dysfunction. Circulation 2018; 137:1463-1471. [DOI: 10.1161/circulationaha.117.031438] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/17/2017] [Indexed: 02/02/2023]
Abstract
Background:
The effect of angiotensin II receptor blockers on right ventricular (RV) function is still unknown. Angiotensin II receptor blockers are beneficial in patients with acquired left ventricular dysfunction, and recent findings have suggested a favorable effect in symptomatic patients with systemic RV dysfunction. The current study aimed to determine the effect of losartan, an angiotensin II receptor blocker, on subpulmonary RV dysfunction in adults after repaired tetralogy of Fallot.
Methods:
The REDEFINE trial (Right Ventricular Dysfunction in Tetralogy of Fallot: Inhibition of the Renin-Angiotensin-Aldosterone System) is an investigator-initiated, multicenter, prospective, 1:1 randomized, double-blind, placebo-controlled study. Adults with repaired tetralogy of Fallot and RV dysfunction (RV ejection fraction [EF] <50%) but without severe valvular dysfunction were eligible. Patients were randomly assigned between losartan (150 mg daily) and placebo with target treatment duration between 18 and 24 months. The primary outcome was RV EF change, determined by cardiovascular MRI in intention-to-treat analysis.
Results:
Of 95 included patients, 47 patients received 150 mg losartan daily (age, 38.0±12.4 years; 74% male), and 48 patients received placebo (age, 40.6±11.4 years; 63% male). Overall, RV EF did not change in patients allocated to losartan (n=42) (44.4±5.1% to 45.2±5.0%) and placebo (n=46) (43.2±6.3% to 43.6±6.9%). Losartan did not significantly improve RV EF in comparison with placebo (+0.51%; 95% confidence interval, –1.0 to +2.0;
P
=0.50). No significant treatment effects were found on secondary outcomes: left ventricular EF, peak aerobic exercise capacity, and N-terminal pro–brain natriuretic peptide (
P
>0.30 for all). In predefined subgroup analyses, losartan did not have a statistically significant impact on RV EF in subgroups with symptoms, restrictive RV, RV EF<40%, pulmonary valve replacement, or QRS fragmentation. However, in a post hoc analysis, losartan was associated with improved RV EF in a subgroup (n=30) with nonrestrictive RV and incomplete remodeling (QRS fragmentation and previous pulmonary valve replacement) (+2.7%; 95% confidence interval, +0.1 to +5.4;
P
=0.045).
Conclusions:
Losartan had no significant effect on RV dysfunction or secondary outcome parameters in repaired tetralogy of Fallot. Future larger studies may determine whether there might be a role for losartan in specific vulnerable subgroups.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT02010905.
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Affiliation(s)
- Jouke P. Bokma
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands (J.P.B., M.M.W., S.M.B., M.G., B.J.M.M., B.J.B.)
- Netherlands Heart Institute, Utrecht (J.P.B., B.J.M.M., B.J.B.)
| | - Michiel M. Winter
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands (J.P.B., M.M.W., S.M.B., M.G., B.J.M.M., B.J.B.)
| | - Arie P. van Dijk
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands (A.P.v.D.)
| | - Hubert W. Vliegen
- Department of Cardiology, Leiden University Medical Center, The Netherlands (H.W.V.)
| | - Joost P. van Melle
- Department of Cardiology, Groningen University Medical Center, The Netherlands (J.P.v.M.)
| | - Folkert J. Meijboom
- Department of Cardiology, Utrecht University Medical Center, The Netherlands (F.J.M.)
| | - Martijn C. Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands (M.C.P.)
| | - Jacqueline K. Berbee
- Department of Hospital Pharmacy, Academic Medical Center Amsterdam, The Netherlands (J.K.B.)
| | - S. Matthijs Boekholdt
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands (J.P.B., M.M.W., S.M.B., M.G., B.J.M.M., B.J.B.)
| | - Maarten Groenink
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands (J.P.B., M.M.W., S.M.B., M.G., B.J.M.M., B.J.B.)
| | - Aeilko H. Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center Amsterdam, The Netherlands (A.H.Z.)
| | - Barbara J.M. Mulder
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands (J.P.B., M.M.W., S.M.B., M.G., B.J.M.M., B.J.B.)
- Netherlands Heart Institute, Utrecht (J.P.B., B.J.M.M., B.J.B.)
| | - Berto J. Bouma
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands (J.P.B., M.M.W., S.M.B., M.G., B.J.M.M., B.J.B.)
- Netherlands Heart Institute, Utrecht (J.P.B., B.J.M.M., B.J.B.)
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49
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Hanneman K, Crean AM, Wintersperger BJ, Thavendiranathan P, Nguyen ET, Kayedpour C, Wald RM. The relationship between cardiovascular magnetic resonance imaging measurement of extracellular volume fraction and clinical outcomes in adults with repaired tetralogy of Fallot. Eur Heart J Cardiovasc Imaging 2017; 19:777-784. [DOI: 10.1093/ehjci/jex248] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/28/2017] [Indexed: 12/14/2022] Open
Affiliation(s)
- Kate Hanneman
- Department of Medical Imaging, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto General Hospital, 585 University Avenue, 1PMB-298, Toronto, Ontario M5G 2N2, Canada
| | - Andrew M Crean
- Department of Medical Imaging, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto General Hospital, 585 University Avenue, 1PMB-298, Toronto, Ontario M5G 2N2, Canada
- Division of Cardiology, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bernd J Wintersperger
- Department of Medical Imaging, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto General Hospital, 585 University Avenue, 1PMB-298, Toronto, Ontario M5G 2N2, Canada
| | - Paaladinesh Thavendiranathan
- Department of Medical Imaging, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto General Hospital, 585 University Avenue, 1PMB-298, Toronto, Ontario M5G 2N2, Canada
- Division of Cardiology, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Elsie T Nguyen
- Department of Medical Imaging, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto General Hospital, 585 University Avenue, 1PMB-298, Toronto, Ontario M5G 2N2, Canada
| | - Camilla Kayedpour
- Division of Cardiology, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rachel M Wald
- Department of Medical Imaging, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto General Hospital, 585 University Avenue, 1PMB-298, Toronto, Ontario M5G 2N2, Canada
- Division of Cardiology, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
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50
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Contijoch FJ, Groves DW, Chen Z, Chen MY, McVeigh ER. A novel method for evaluating regional RV function in the adult congenital heart with low-dose CT and SQUEEZ processing. Int J Cardiol 2017; 249:461-466. [PMID: 28970037 DOI: 10.1016/j.ijcard.2017.08.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/17/2017] [Accepted: 08/14/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Measuring local RV function in adult congenital heart disease (ACHD) with echocardiography or MRI is challenging because of the complex geometry and existing pacing devices. Visual assessment of ventricular function via low-dose cardiac CT has been recently performed. This pilot study assessed whether low-dose 4D cine CT combined with automatic measurement of regional shortening could quantify right-ventricular function in ACHD patients. METHODS Seven patients with Tetralogy of Fallot either contraindicated for MRI or assessed for coronary artery disease and seven non-congenital patients were imaged with ECG-gated cardiac CT utilizing a 320-detector row scanner. Right ventricular global function and regional shortening were quantified. RESULTS Non-congenital patients were imaged with 2.9±2.1mSv and 395±359 HU blood-myocardium contrast. The ACHD patients were imaged with 2.1±1.3mSv and 726±296 HU contrast. Right ventricles of the ACHD patients had higher end-diastolic volume (297±107mL vs 123±34mL, p=0.001), lower ejection fraction (32.0±4.9% vs 45.0±6.0%, p=0.001), and higher dyskinetic fraction (10.9±3.7% vs 2.6±2.8%, p<0.001) relative to the non-congenital controls. CONCLUSIONS In this initial pilot study, right ventricular global and regional systolic function were measured using low-dose cine CT with SQUEEZ quantification in non-congenital patients as well as ACHD patients with Tetralogy of Fallot. Unique regional features of RV dyskinesia were identified in the ACHD patients which could yield a more precise quantification of RV function.
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Affiliation(s)
- Francisco J Contijoch
- Department of Bioengineering, UC San Diego, La Jolla, CA, United States; Department of Radiology, UC San Diego, La Jolla, CA, United States
| | - Daniel W Groves
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Zhennong Chen
- Department of Bioengineering, UC San Diego, La Jolla, CA, United States
| | - Marcus Y Chen
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Elliot R McVeigh
- Department of Bioengineering, UC San Diego, La Jolla, CA, United States; Department of Radiology, UC San Diego, La Jolla, CA, United States; Division of Cardiology, Department of Medicine, UC San Diego, La Jolla, CA, United States.
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